What important, immediate postoperative care practice should the nurse remember when caring for a woman who has had a mastectomy?
Venipuncture for blood work should be performed on the affected arm.
The blood pressure (BP) cuff should not be applied to the affected arm.
The affected arm should be held down close to the woman's side.
The affected arm should be used for intravenous (IV) therapy.
The affected arm should be used for intravenous (IV) therapy.
The Correct Answer is B
Choice A reason: This is incorrect because venipuncture for blood work should be avoided on the affected arm. The mastectomy may have involved the removal of lymph nodes, which can impair the lymphatic drainage and increase the risk of lymphedema (swelling) in the arm. Venipuncture can cause further damage or infection to the arm.
Choice B reason: This is correct because the BP cuff should not be applied to the affected arm. The BP cuff can exert pressure on the arm and interfere with the blood and lymph flow. This can also increase the risk of lymphedema or pain in the arm.
Choice C reason: This is incorrect because the affected arm should not be held down close to the woman's side. The woman should be encouraged to elevate the arm above the level of the heart and perform gentle exercises to promote circulation and prevent stiffness. The arm should not be immobilized or restricted.
Choice D reason: This is incorrect because the affected arm should not be used for IV therapy. IV therapy can introduce fluids or medications into the arm that can affect the blood and lymph flow. It can also cause irritation or infection to the arm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Biophysical profile is a test that assesses the fetal well-being by measuring five parameters: fetal breathing movements, fetal movements, fetal tone, amniotic fluid volume, and fetal heart rate. It does not predict chromosomal abnormalities in the fetus.
Choice B reason: Lecithin/sphingomyelin [L/S] ratio is a test that measures the amount of two phospholipids in the amniotic fluid. It is used to evaluate the fetal lung maturity and the risk of respiratory distress syndrome. It does not predict chromosomal abnormalities in the fetus.
Choice C reason: Type and crossmatch of maternal and fetal serum is a test that determines the blood type and Rh factor of the mother and the fetus. It is used to identify the risk of hemolytic disease of the newborn due to Rh incompatibility. It does not predict chromosomal abnormalities in the fetus.
Choice D reason: Multiple-marker screening is a test that measures the levels of four substances in the maternal serum: alpha-fetoprotein, human chorionic gonadotropin, unconjugated estriol, and inhibin A. It is used to estimate the risk of Down syndrome, trisomy 18, and neural tube defects in the fetus.
Correct Answer is C
Explanation
Choice A reason: This is not the correct action, as the rate is not within normal limits. A normal FHR at 30 weeks of gestation is between 110 and 160 beats/min. A rate of 82 beats/min is considered bradycardia (slow heart rate), which can indicate fetal distress or hypoxia (low oxygen).
Choice B reason: This is not the first action, but it may be necessary after confirming the FHR. The nurse should first rule out the possibility of a maternal-fetal heart rate confusion, which can occur when the maternal heart rate is mistakenly counted as the FHR. This can happen if the Doppler or the electronic fetal monitor is placed too close to the maternal pulse or if the maternal heart rate is unusually slow².
Choice C reason: This is the correct action, as it can help differentiate between the maternal and the fetal heart rate. The nurse should assess the woman's radial pulse at the same time as listening to the FHR and compare the rates and rhythms. If the rates are the same or very close, it is likely that the nurse is hearing the maternal heart rate instead of the FHR. If the rates are different, it is likely that the nurse is hearing the FHR and that the fetus has bradycardia.
Choice D reason: This is not the correct action, as it may cause unnecessary anxiety or distress for the woman. The nurse should not allow the woman to hear the heartbeat until the FHR is confirmed and the cause of the bradycardia is determined. The nurse should also explain the situation to the woman and provide reassurance and support.
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